The effect of health visitors’ postpartum home visit frequency on first-time mothers: Cluster randomised trial
Introduction
The family is an important social system that impacts the long-term wellbeing of its members (Rogers, 1996). The arrival of a new infant has been identified as a stressful family transition period when parents need to manage infant care and balance life demands within a context of physical, lifestyle and emotional changes (Christie et al., 2008, McVeigh, 1997). Yet, it has been suggested that parenting beliefs and behaviours may be most amenable to change during the postpartum period (van Ijzendoorn and Bakermans-Kranenburg, 1997). In consequence, international guidelines reinforce the importance of postpartum health care (WHO, 1999).
‘Home visiting’ is a care provision strategy that has been used to address a wide range of issues that affect health and wellbeing of family units or individual members, including physical, psychological, educational, lifestyle, parenting, interactional and environmental needs (Elkan et al., 2000a, Elkan et al., 2000b, Gomby et al., 1999). Many programmes begin in the antepartum and progress to the postpartum period (Bull et al., 2004, Shaw et al., 2006a, Shaw et al., 2006b).
In general, research studies identify small and mixed effects of home visiting, however, there is systematic review evidence that suggests home visiting reduces child maltreatment (Gomby et al., 1999) and improves maternal mood outcomes (Shaw et al., 2006a, Shaw et al., 2006b). Most evidence however, is based on traditional statistical methods and individual-randomised control designs. Such statistics and designs average the family outcome effects of a programme across every home visitor. Each home visitor, however, is likely to offer unique and individualised approaches to the care they provide (Gomby et al., 1999). This may produce a ‘clustering effects’ in which families visited by the same home visitor share some degree of similarity in their outcomes. Where such clustering effects exist, traditional design and statistical techniques overestimate programme effectiveness (Plewis, 2002). Yet, comparatively few studies (Chaffin et al., 2001, Goodson et al., 2000, McArthur et al., 2003) have used either a cluster randomised design or appropriate statistical techniques (such as multilevel modelling) to assess and control for home visitor clustering effects.
Most international home visiting studies have investigated the effect of home visiting on families deemed to be psychosocially ‘at-risk’ (Elkan et al., 2000a, Elkan et al., 2000b). Olds et al's work (Olds et al., 1999) concludes that intensive nurse led programmes (50 home visits over 2 years, if mother was recruited at 18 weeks gestation) benefit the neediest families (low-income, unmarried women), but provide little benefit for the broader population. Yet, it has been suggested that all first-time ‘lower risk’ parents with no identified health concerns (other than normative and adaptive needs) may benefit from supportive postpartum visitation (Hall and Elliman, 2003, Ministerial Group on the Family, 1998).
Universal services provide population based services to all families regardless of risk status. Currently, there is little systematic review evidence to support the provision of universal postpartum provision (Shaw et al., 2006a, Shaw et al., 2006b). Various studies (Escobar et al., 2001, Lieu et al., 2000, Petrou et al., 2004) have compared postpartum outcomes for ‘low-risk’ mothers and their infants who had shorter postpartum hospital stays (control) with families offered additional postpartum home visits (intervention). In combination, these investigations provide no evidence concerning postpartum visiting effects on breastfeeding continuation or maternal depressive symptoms; however, increased contact increased users’ care satisfaction (Escobar et al., 2001, Lieu et al., 2000).
Health visitors are United Kingdom (UK) registered Specialist Community Public Health Nurses who offer home based and clinic based services to all families with young children (NIHPSSME, 1995). This service is free to families under the auspices of the National Health Service (England, Scotland and Wales) and Department of Health, Social Services and Public Safety (Northern Ireland). The balance of health visitors’ care between that which is provided universally (given to everyone, irrespective of risk) or targeted at those at most risk, has been debated (Elkan et al., 2000a, Elkan et al., 2000b, Guterman, 1999). There is evidence that health visitor and midwife care can successfully alleviate maternal low mood and prevent postnatal depression (Holden et al., 1989, McArthur et al., 2003). The general effect that health visiting has on ‘lower risk’ families (who receive most universal care provision) is currently undetermined and recent UK reviews indicated a need to evaluate the effect of routine home visiting offered by health visitors (Bull et al., 2004, Elkan et al., 2000a, Elkan et al., 2000b).
‘Home visiting’ has been described as the most important service delivery strategy for assessing maternal and infant relationships (Wilson et al., 2008) and that ongoing nurse–family contact is required for accurate assessment of family need (Appleton and Cowley, 2008a, Appleton and Cowley, 2008b). Yet, health visitors are only required to make one home visit during the first 8 postpartum weeks (NIHPSSME, 1995). It has been advocated, however, that weekly visits to all first-time parents during the early postpartum period may be beneficial (Ministerial Group on the Family, 1998). The relative merits of either frequency of home visiting are unknown and several studies have only found short-term postpartum intervention effects (Cooper et al., 2003, Fraser et al., 2000). Although no study has yet demonstrated a minimum number of home visits to achieve a beneficial programme outcome, it has been postulated that a minimum ‘number of visits’ threshold may need to be exceeded before family change occurs (Gomby et al., 1999).
Section snippets
Objective and design
The objective of this study was to determine the effect of frequency of health visitors’ postpartum home visiting on ‘low-risk’ first-time families’ outcomes at 8 weeks postpartum and 7 months follow-up. To meet this objective, a cluster randomised trial was conducted in which health visitors were randomised to treatment or control groups. Each health visitor offered their participating families the same duration of postpartum home visits. This duration of care was randomly assigned as either
Results
Of the n = 80 health visitors who actively participated in the trial, n = 39 were randomly allocated to ‘intervention’ and n = 41 to ‘control’ groups. Initially 296 mothers were recruited, n = 280 (94.6%) completed outcome measures by 8 weeks (end of intervention) and n = 256 (86.5%) at 7 months (follow-up). Most participants (n = 159, 57%) had health visitors who had been allocated to the control group. The average cluster size/number of mother participants per health visitor was 3.7 (range 1–12). Twelve
Discussion
The objective of this study was to determine the effect of frequency of health visitors’ home visits on ‘low-risk’ first-time families’ outcomes to 8 weeks postpartum and 7 months follow-up. A cluster randomised trial with multilevel statistical analysis was undertaken to account for clustering effects associated with variations in health visitors’ care practices. In addition, mothers’ pre-health visiting parenting/health status, well-baby clinic attendance and health visitor antenatal contact
Conclusion
While postpartum care and early interventions have international and national policy relevance (DHSSPS, 2010, DCSF, 2010, World Health Organisation, 1999), the current study found that weekly home visits to low-risk first time mothers had variable effects on family outcomes to 7 months postpartum. It has been asserted that many factors must be in place before positive results from home visiting studies can be achieved (Gomby et al., 1999). Examination of the MacArthur et al.’s (2003)
Acknowledgements
We would like to thank the parents and health visitors who so willingly took part in this study and the locality managers who kindly facilitated recruitment staff and clients. In addition, we thank and acknowledge the contribution of our colleague, Professor Brenda Poulton who facilitated access to the research area and contributed to preliminary qualitative research design work, selection of a service satisfaction questionnaire.
In addition, JC would like to acknowledge Professor Linda Johnston
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